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total knee arthroplasty for posttraumatic arthritis than for primary arthritis
Alexandre Lunebourg, Sebastien Parratte, André Gay, Matthieu Ollivier, Kleber Garcia-Parra, Jean-Noël Argenson
To cite this version:
Alexandre Lunebourg, Sebastien Parratte, André Gay, Matthieu Ollivier, Kleber Garcia-Parra, et al.. Lower function, quality of life, and survival rate after total knee arthroplasty for posttraumatic arthritis than for primary arthritis. Acta Orthopaedica, Informa Healthcare, 2015, 86, pp.189-194.
�10.3109/17453674.2014.979723�. �hal-01216690�
Lower function, quality of life, and survival rate after total knee arthroplasty for posttraumatic arthritis than for primary arthritis
Alexandre Lunebourg
1,3, Sebastien PArrAtte
1,3, André gAy
2,3, Matthieu oLLivier
1,3, Kleber gArciA-PArrA
1, and Jean-noël ArgenSon
1,31
Department of orthopedic Surgery APHM, iML, Sainte Marguerite Hospital;
2Department of Plastic Surgery APHM, iML, Sainte Marguerite Hospital;
3
Aix-Marseille university, cnrS, iSM uMr 7287, Marseille, France.
correspondence: [email protected] Submitted 2014-02-21. Accepted 2014-08-14.
Open Access - This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.
DOI 10.3109/17453674.2014.979723
Background and purpose — Total knee arthroplasty (TKA) for treatment of end-stage posttraumatic arthritis (PTA) has specific technical difficulties and complications. We compared clinical outcome, postoperative quality of life (QOL), and survivorship after TKA done for PTA with those after TKA performed for pri- mary arthritis (PA).
Patients and methods — We retrospectively reviewed patients who were operated on at our institution for PTA between 1998 and 2005 (33 knees), and compared them to a matched group of patients who were operated on for PA during the same period (407 knees). Clinical outcomes and postoperative QOL were compared in the 2 groups using Knee Society score (KSS), range of motion (ROM) of the knee, and the knee osteoarthritis outcomes score (KOOS). Implant survival rate was calculated using Kaplan- Meier analysis.
Results — At a mean follow-up of 11 (5–15) years, KSS knee increased from mean 39 (SD 18) to 87 (SD 16) in the PA group (p = 0.003), and from 31 (SD 11) to 77 (SD 15) in the PTA group (p = 0.003). KSS function increased from 55 (12) to 89 (25) in the PA group (p = 0.008) and from 44 (SD 14) to 81 (SD 10) in the PTA group (p = 0.008). Postoperative ROM also improved in both groups, from 83° to 108° in the PTA group (p < 0.001) as opposed to 116° to 127° in the PA group (p = 0.001), with lower results in the PTA group (p < 0.001). KOOS was lower in the PTA group (p
< 0.001). The survival rate of TKA at 10 years with an endpoint defined as “any surgery on the operated knee” showed better results in the PA group (99%, CI: 98–100 vs. 79%, CI: 69–89; p
< 0.001).
Interpretation — Patients and surgeons should be aware that clinical outcome and implant survival after TKA for PTA are lower than after TKA done for PA
Posttraumatic arthritis (PTA) of the knee is a common com- plication of intra- or extra-articular fracture of the knee, with incidence estimated to be from 21% to 44%. There are con- flicting views concerning the best management of fractures around the knee, but it is generally accepted that articular irregularity, misalignment of the lower limb, and joint insta- bility are the leading causes of PTA (Rademakers et al. 2007, Schenker et al. 2014). In end-stage PTA, when nonoperative treatment has failed, TKA is a valid option (Bedi and Haid- ukewych 2009). In PTA, surgeons have to deal with technical difficulties including previous scars, possible history of infec- tion, misalignment related to malunion, stiffness, and some- times ligament imbalance. Thus, performing TKA in PTA is more challenging than in primary osteoarthritis.
Conflicting results have been reported concerning TKA in PTA. Several publications have described the challenges and outcomes after TKA for PTA, with a high rate of complica- tions (from 17% to 57%) (Lonner et al. 1999, 2000, Saleh et al. 2001, Buechel 2002, Papadopoulos et al. 2002, Weiss et al.
2003a and b, Haidukewych et al. 2005, Wu et al. 2005, Morag
et al. 2006, Papagelopoulos et al. 2007), whereas some studies
have found good results in young patients who have had TKA
for secondary traumatic osteoarthritis (Dalury et al. 1995, Tai and Cross 2006). We therefore compared (1) the functional improvement, (2) quality of life (QOL) postoperatively, and (3) implant survival rate of TKA for PTA with the same parameters for TKA performed for primary arthritis (PA).
Patients and methods Patient selection
In this retrospective study, all patients who were operated on at our institution for a PTA between 1998 and 2005 (the PTA group) were included and compared to a matched group of patients who were operated on for primary arthritis during the same period (the PA group). Using the computerized database at our institution, we identified 1,757 primary unilateral TKAs that were performed during the study period for an end-stage tri-compartmental osteoarthritis of the knee according to the Ahlback grading system (Ahlback 1968). In the PTA group, we included patients with a previous history of intra-articular and extra-articular fracture around the knee, regardless of the initial treatment of the fracture. In both groups, patients treated with unicompartmental knee arthroplasties were excluded and a minimum follow-up of 5 years was required. 33 TKAs of the 1,757 (2%) (involving 33 patients) were done because of PTA and 1,628 of the 1,757 (93%) were TKAs for PA. Among the unilateral cases in the PA group, based on clinical records and the institutional database, patients were matched accord- ing to demographics including age, BMI, Charnley classifi- cation, and follow-up. Following this matching, 407 patients (407 knees) were assigned to the PA group and compared to the PTA group (Table 1). In the PTA group, the mean delay from the original trauma to TKA was 14 (SD 7) years. Ini- tial fracture management, fracture characteristics, amount of bone loss (classified according to the Anderson Orthopaedics Research Institute Bone Defect Classification (Jacofsky el al.
2010)), and scar pattern are reported in Table 2.
Surgical procedure
Before TKA, all patients had had a standardized preoperative radiographic evaluation including anteroposterior (AP), lat- eral, varus, and valgus stress radiographs and Merchant views of the knee, in addition to a full-length standing hip-to-ankle radiograph.
In the PA group, a cemented posterior-stabilized TKA (LPS Flex Mobile; Zimmer, Warsaw, IN) was used in all cases. A standard medial parapatellar approach was always performed, both femoral and tibial components were cemented, and the patella was systematically resurfaced. No additional osteoto- mies were necessary for the purpose of exposure in the PA group. No intraoperative fractures were reported.
In the PTA group, a standard postero-stabilized TKA was used for 17 patients (Nexgen; Zimmer), and an augmented posterior-stabilized TKA was used for 16 patients (LCCK with standard PS insert; Zimmer). All the implants were cemented and the patella was always resurfaced. Cutane- ous approach was chosen according to previous surgeries, then a standard medial parapatellar approach was used and 3 times osteotomies of the tibial tuberosity were necessary. 6 patients underwent a proximal tibial osteotomy and 3 patients underwent a distal femoral osteotomy simultaneously with TKA due to a malunion leading to a frontal deformity greater than 10 degrees. For all the cases requiring an osteotomy, the osteotomy was done to correct an extra-articular malunion.
4 patients with knee stiffness required soft tissue release. 13 patients (6 femurs and 7 tibias) presented a severe bone defect classified as type 2, which needed stems and augments (Figure 1). In 3 patients with severe demineralized bone, a femoral or tibial stem extension was used. No intraoperative fractures were noted.
Follow-up and method of evaluation
At our institution, regular clinical and radiographic follow-up after TKA is performed at 3 months, 1 year, 2 years, 5 years, and every 5 years thereafter (standard AP, lateral and full-
table 1. Summary of the main characteristics of the patients in the 2 groups
Primary Posttraumatic arthritis (PA) arthritis (PTA)
group group
n = 407 n = 33 p-value
Age (years)
a72 (9) 69 (11) 0.09
Gender (M:F) 132:275 18:15 0.01
BMI (kg/m
2)
a29 (5) 27 (5) 0.09
Previous knee surgeries (n)
a0.36 (0.73) 1.6 (0.93) 0.003 Charnley classification
A 323 27 0.7
B 84 6 0.7
C 0 0 –
Follow-up
a11 (3) 11 (3) 0.4
a
Mean (SD)
table 2. Summary of the main characteristics of fractures and scar patterns in the PtA group
Mean delay from original trauma to TKA (SD) 14 (7) years Initial management of the fracture: Operatively 28
Nonoperatively 5
Fracture location: Intra-articular 22
Extra-articular 11
Bone involved: Tibia 23
Femur 6
Tibia and femur 4 AORI bone defect classification:
aType 1 20
Type 2 13
Number of scars: 1 scar 14
2 scars 10
3 scars and more 4
a
Anderson Orthopaedics Research Institute bone defect classifica-
tion (Jacofsky el al. 2010).
length standing hip-to-ankle radiographs). The Knee Society knee score and function score (Insall et al. 1989) and range of knee flexion (using a goniometer) were recorded preopera- tively and at the follow-up visits. Data were collected prospec- tively. Patients were reviewed and the quality of life (QOL) of patients was determined at the last follow-up using the vali- dated version of the self-administrated KOOS (Ornetti et al 2007). At the last review, 30 patients were available in the PTA group: 2 patients had died and 1 patient was lost to follow-up.
402 patients were available in the PA group: 3 patients had died and 2 patients were lost to follow-up. For these 8 patients who had died or were lost to follow-up, the routine 5-year
follow-up examination was used. The mean follow-up was 11 (5–15) years.
The survival rate of TKA in both groups was calculated according to Tew and Waugh (1982) and was assessed with 2 different endpoints. The first endpoint was defined as “any surgery on the operated knee” and the second was defined as
“prosthesis revised for mechanical failure or infection”. Com- plications were reported as a reoperation when no implant exchange was performed, and as a revision if the prosthesis had been removed and replaced.
Statistics
The characteristics of patients, results of KSS knee, KSS function, ROM, and results of the KOOS score are reported as mean (SD). Qualitative variables were compared using chi- squared test and quantitative variables were compared with Student’s t-test. QOL was compared between groups at last follow-up. The Mann-Whitney test for matched-pair com- parisons was used to analyze results of clinical outcomes and QOL. Any p-value < 0.05 was considered to be statistically significant. In survivorship analysis, Mantel-Cox log rank was used to assess significance during the construction of all Kaplan-Meyer curves. Confidence intervals (CIs) at the 95%
level were determined.
Ethics
Institutional Review Board (IRB)/Ethics Committee approval was obtained (no. 2010-124664-32).
results
At the last follow-up (Table 3), in the PA group the mean KSS knee value improved from 39 (SD 18) to 87 (SD 16) (p
= 0.003) and in the PTA group, it improved from 31 (SD 11) to 77 (SD 15) (p = 0.003). Thus, the mean KSS knee value in the PTA group was significantly lower than in the PA group (p
= 0.02), but the amount of improvement between the 2 groups was similar (p = 0.4). The mean KSS function improved from 55 (SD 12) to 89 (SD 25) in the PA group (p = 0.008), and from 44 (SD 14) to 81 (SD 10) in the PTA group (p = 0.008). The mean KSS function value was therefore significantly lower in the PTA group than in the PA group (p = 0.03), but the amount of improvement between the 2 groups was similar (p = 0.3).
Postoperative ROM also improved in both groups, from 83°
to 108° (p < 0.001) in the PTA group and from 116° to 127° (p
= 0.001) in the PA group. Thus, even though the improvement in ROM was better in the PTA group (25° as opposed to 11°), the results were significantly lower than in the PA group (p <
0.001) and the amount of improvement between the 2 groups was significantly different (p < 0.001).
Lower QOL scores were observed in the PTA group for the 5 subcategories of the KOOS (Figure 2). In the PA group, the mean KOOS pain value was 86 (SD 17) points and it was
Figure 1. A typical case: a 60-year-old active man with a history of
fracture of the medial tibial plateau. TKA required use of stems and
augments and a muscular flap. At 8 years, the patient is doing well but
still has limitation of flexion at 105° and is limited during his activities of
daily living. The implant is radiographically stable.
72 (SD 20) points in PTA group; the mean KOOS symptoms values were 85 (SD 16) and 68 (SD 15); the mean KOOS activities of daily living values were 85 (SD 18) and 69 (SD 21); the mean KOOS sport activities values were 70 (SD 32) and 31 (SD 18); and the mean KOOS quality of life values were 78 (26) and 55 (25). There were significant differences between groups in all dimensions of KOOS (p < 0.001).
Survival rate at 10 years considering first the endpoint defined as “any surgery on the operated knee” was signifi- cantly lower (p < 0.001) in the PTA group (79%, CI: 69–89) than in the PA group (99%, CI: 98–100), with reoperation mainly performed within the 2 first years after the TKA. Sur- vival rate considering the second endpoint defined as “pros- thesis revised for mechanical failure or infection” was also significantly lower (p = 0.002) in the PTA group (94%, CI:
89–99) than in the PA group (100%, CI: 99–100).
At the last follow-up, the overall rate of complications was significantly higher in the PTA group than in the PA group (p
< 0.001) (Table 4).
Discussion
We found worse clinical results in the PTA group than in the PA group in terms of pain, flexion, walking ability, and stair climbing. The QOL was also significantly worse in the PTA group than in the PA group. Finally, one-fifth of the patients in the PTA group required a reoperation within 2 years after TKA. The 10-year survivorship was also lower in the PTA group than in the PA group. It is worth noting that the net improvement over baseline in subjective and functional scores was similar for PTA TKAs and TKAs performed for osteoar- thritis. This suggests that the overall differences noted in these parameters may be largely due to differences in the preopera- tive status of the patients rather than being intrinsic to the suc- cess of the procedure. In other words, the procedure improved the subjective parameters equally in both patient groups, and the PTA group simply started with worse knee function.
Our study had certain limitations. Most importantly, it was retrospective. Secondly, patients included in the PTA group had initially had different modalities of fracture management,
table 3. Medium-term results of clinical outcomes and range of motion (roM) in both groups preoperatively and at the last follow-up.
values are mean (SD)
Primary arthritis (PA) group (n = 407) Posttraumatic arthritis (PTA) group (n = 33)
Preop. At last FU Improvement p-value
aPreop. At last FU Improvement p-value
ap-value
bp-value
cKSS
Knee 39 (18) 87 (16) 48 0.003 31 (11) 77 (15) 46 0.003 0.02 0.4
Function 55 (12) 89 (25) 34 0.008 44 (14) 81 (10) 37 0.008 0.03 0.3
ROM (°) 116 (16) 127 (13) 11 0.001 83 (19) 108 (17) 25 < 0.001 < 0.001 < 0.001
a
Comparison between preoperative results and results at last follow-up in each group.
b
Comparison of results between the 2 groups at the last follow-up.
c Comparison of improvement between 2 groups.
FU: follow-up; KSS: Knee Society score; ROM: range of motion.
table 4. overall rate of complications
aPA group PTA group
n = 407 n = 33
Prosthesis revised
Deep infection 2
Aseptic loosening 1
Reoperation
Knee stiffness 1 2
Patellar clunk syndrome 1
Heterotopic ossification 1
Hematoma 1
Chronic patellar dislocation 1 Early polyethylene wear 1 Superficial wound infection 1
Overall complications (p < 0.001) 5 7
a
At the last follow-up, the overall rate of complications was higher in the PTA group than in the PA group (p < 0.001). Complications were reported as revision if the prosthesis was removed and replaced, and as reoperation when no implant exchange was performed.
Figure 2. Postoperative results of the KOOS for the 2 groups (the pri- mary arthritis (PA) group and the posttraumatic arthritis (PTA) group).
ADL: activities of daily living; SA: sport activity; QoL: quality of life.
There were significant differences between groups in all dimensions of KOOS (p < 0.001).
100 80 60 40 20 0
PA group PTA group
Pain Symptoms ADL SA QoL
